- Email: [email protected]
Night Eating Syndrome: Report of a family case
Eating Behaviors 22 (2016) 83–86
Contents lists available at ScienceDirect
Eating Behaviors
Night Eating Syndrome: Report of a family case Güzin M. Sevinçer a,⁎, Kelly C. Allison b a
Istanbul Gelisim University, Department of Psychology, Istanbul, Turkey Perelman School of Medicine at the University of Pennsylvania Center for Weight and Eating Disorders (Suite 3027) and Stunkard Weight Management Program (Mezzanine), 3535 Market Street, Philadelphia, PA 19104-3309, United States
b
a r t i c l e
i n f o
Article history: Received 6 April 2015 Received in revised form 22 March 2016 Accepted 30 March 2016 Available online 06 April 2016 Keywords: Night Eating Syndrome Familial Genetic
a b s t r a c t Night eating syndrome (NES) represents a circadian delay in the pattern of eating. As there are genetic links for other eating- and circadian-based disorders, it is likely that there is a genetic basis for NES as well. We present a family case study of three identified patients and their extensive family history of NES and co-morbid mood disorders. This case report suggested that NES may have a heritable feature, particularly nocturnal ingestions. Of the seven identified cases, four had co-morbid mood disorders, and all descended from a couple with bipolar disorder and delusional disorder. More work is needed to understand the extent of genetic influence on NES, and the relationship between NES and other psychiatric disorders. © 2016 Elsevier Ltd. All rights reserved.
1. Introduction and objective Night Eating Syndrome (NES) is characterized by recurrent episodes of night eating, as manifested by eating after awakening from sleep or by excessive food consumption after the evening meal. Specifically, at least two episodes of nocturnal eating (rising from bed during the sleep period and eating) should occur per week, or 25% or more of one's daily food intake should occur after dinner. Awareness and recall of the eating is required to be diagnosed with NES, as is significant distress or impairment caused by the disorder. An exclusion criterion for diagnosis of NES is another medical disorder or psychiatric disorder that might better explain the disordered eating pattern. An additional criterion requires that the disordered pattern of eating should be maintained for at least 3 months (Allison, Lundgren, & O'Reardon, 2010; American Psychiatric Association, 2013). Although (NES) did not ultimately make the cut as an official diagnosis, the Diagnostic and Statistical Manual, 5th Edition recognized the clinical significance of NES as a category of “Other Specified Feeding or Eating Disorder” (American Psychiatric Association, 2013). Regarding the etiology, ingestion of food seen in patients with NES is conceptualized as a delay in the circadian pattern of food intake (O'Reardon et al., 2004). Although the etiology of NES is unclear, it is
⁎ Corresponding author at: İstanbul Gelişim Üniversitesi Psikoloji Bölümü Cihangir mah. Şehit Jandarma Komando Er Hakan Öner Sk. No:1 34315 Avcılar, İSTANBUL, TURKEY. E-mail addresses: [email protected] (G.M. Sevinçer), [email protected] (K.C. Allison).
http://dx.doi.org/10.1016/j.eatbeh.2016.03.022 1471-0153/© 2016 Elsevier Ltd. All rights reserved.
thought that genetic factors may be involved (Lundgren, Allison, & Stunkard, 2006; Root et al., 2010). However, only a small number of studies have been conducted about this. Reports of familial aggregation of NES have represented a first step in understanding potential genetic and environmental influences (Lamerz et al., 2005; Lundgren et al., 2006; Root et al., 2010). In this family case report we present the familial aggregation of NES in a single family, which may provide evidence for genetic inheritance factors involved in the etiology of NES. We describe these cases in the following text.
2. Case report Three individuals from the same family were referred to a psychiatry clinic and were diagnosed as having NES by psychiatrists specializing in eating disorders. They used a routine clinical examination based on the proposed diagnostic criteria for NES (Allison et al., 2010). A remarkable finding in those cases was the discovery that several first-degree relatives also engaged in nighttime eating and were invited for an interview. Those who could not participate in a routine clinical interview were contacted for a telephone interview. The family pedigree shown below was generated following psychiatric diagnoses of the three presenting family members and from information obtained from interviewed individuals regarding the other family members. Four of the 17 family members refused to participate. Information about the psychiatric diagnosis of family members who were not interviewed was confirmed by at least two other family members to be included in this report. We have
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G.M. Sevinçer, K.C. Allison / Eating Behaviors 22 (2016) 83–86
Fig. 1. Cases are listed in this figure who were interviewed in person as yellow, were interviewed by phone as blue, refused to participate as green, recorded with a confirmation of at least two family members as purple, and were deceased as strikethrough. (For interpretation of the references to color in this figure legend, the reader is referred to the web version of this article.)
included diagnoses when family members had been under psychiatric treatment with a recorded diagnosis. Unverifiable information obtained from family members was not included. Definite diagnosis by a psychiatrist is recorded with the confirmation of participant family members or confirmation of medical records if they were deceased. Cases are listed in Fig. 1 below who were interviewed in person as yellow, were interviewed by phone as blue, refused to participate as green, recorded with a confirmation of at least two family members
as purple, and were deceased as strikethrough. All cases that were diagnosed with NES shared a similar symptom profile. They all reported having nocturnal ingestions most days of the week for many years (2– 20 years). They also had morning anorexia and consumed N 25% of intake after dinner accompanied by marked depressive symptoms. Surprisingly most of the cases did not complain about their night eating as they considered it a normal condition. All cases were obese or overweight. Only detailed information of presenting family members are depicted below.
G.M. Sevinçer, K.C. Allison / Eating Behaviors 22 (2016) 83–86
2.1. Case 1 (Index Case) 47-year-old married housewife with a 20-year history of night eating. She felt difficulty in initiating sleep without eating something most days. She reported one or two awakenings associated with consumption of food, especially sweets and snacks 3–5 times per week. For most of the day, especially days after she had nocturnal ingestions, she reported lack of appetite until 2 pm. She had gained about 5 kg in the last 6 months, during which time her BMI rose from 29.9 kg/m2 to 31.3 kg/m2 (160 cm, 80 kg), which she attributed to increased evening calorically dense meals. Her mood was significantly depressed with existing stressful life events such as unemployment of her husband. She was under antidepressant treatment (escitalopram) for her depression and anxiety for about 3 years. She also complained of persistent lack of sexual desire. She believed that her nocturnal eating habits were normal as almost every family member experienced such an eating pattern. She reported that her son, daughter, brothers, sister, nephews and nieces all had this night eating pattern. She also reported that one of her sisters suffered from night eating for years but that sister's symptoms spontaneously disappeared 2 years ago. She denied that her nighttime ingestions negatively impacted her life. However, she complained about her weight gain. Her psychiatric examination revealed depressed mood, fatigue, anxiety, irritability, and obsessive personality features. She denied alcohol use. She increased smoking cigarettes with accompanying life stressors. She scored a 29 on the Night Eating Questionnaire (Allison et al., 2008), suggestive of the presence of night eating symptoms, and a 19 on Beck Depression Inventory (Beck, Ward, Mendelson, Mock, & Erbaugh, 1961), suggesting mild to moderate symptoms of depressed mood.
85
adolescence. She reported consuming N25% of daily caloric intake after dinner and morning anorexia. She believed that her citalopram treatment was aggravating her nocturnal eating frequency but alleviating evening hyperphagia. Despite endorsing the diagnostic criteria for NES, she only scored a 19 on the Night Eating Questionnaire (this is below the cut score of 25 suggestive of NES), and a 16 on the Beck Depression Inventory, indicating mild depressive symptoms. 2.4. Additional family cases Four additional family members were interviewed by phone and met criteria for NES (see Fig. 1). The common feature among the affected family members was the presence of nocturnal ingestions. Evening hyperphagia was not a common complaint among the cases. These other cases were as follows. The 52 year old brother of Case #1 met criteria for NES and he also reported a diagnosis of bipolar disorder for which he was treated with lithium. He weighed 140 kg and his height was reported at 175 cm for a BMI of 45.7 kg/m2. The 50 year old sister of Case #1 also met criteria for NES. She reported having nocturnal ingestions almost nightly for the past 10 years. She also described pronounced morning anorexia. She reported a height of 158 cm and a weight of 83 kg, yielding a BMI of 33.2 kg/m2. The remaining two cases were nieces of Case #1. The first was 27 years old with a height of 164 cm and a weight of 76 kg with a BMI of 28.3 kg/m2, and the second was and 30 years old with a height of 161 cm and weight of 72 kg, yielding a BMI of 27.8 kg/m2. Both nieces reported the regular presence of nocturnal ingestions with full awareness and morning anorexia, similar to the other cases presented within this family. The symptom profiles of NES cases are presented in Table 1. 3. Discussion
2.2. Case 2 The son of case #1 was a 22-year-old single male and a university student. He had been diagnosed 2 years ago as having bipolar I disorder, with a treatment of valproic acid 1000 mg/day in his military service. He had also been treated with imipramine for his nocturnal enuresis and somnambulism when he was 14. He had been euthymic for the past 3 months. He reported that his mood stability was deteriorating due to problems in his intimate relations. His height measured 175 cm and his weight was 90 kg, yielding a BMI of 30 kg/m2. He scored 25 on the Night Eating Questionnaire, just reaching the threshold suggestive of NES symptoms, and a 3 on the Beck Depression Inventory, indicating minimal depressive symptoms. He reported the same eating pattern as his mother. He stated that he could not initiate sleep unless he ate something. He reported full awareness of his awakenings to eat, with these events occurring 3–4 times per week. He did not have any sleep related complaints during the daytime. He also reported morning anorexia. However, he was unsure if he was consuming N 25% of daily caloric intake after dinner. His mood was stable, but he felt better during the daytime. 2.3. Case 3 The niece of case #1 was a 32-year-old married housewife with a 12year history of night eating. She thought that she had felt depressed for many years. She complained of somatic symptoms such as headache, fatigue, and loss of libido. She reported that she was eating just before attempting to sleep almost daily to overcome her difficulty with initial insomnia. She described a childhood sexual abuse history and was treated with antidepressants such as imipramine, venlafaxine, citalopram and escitalopram. Case 3 reported a current effort to lose weight with a strict diet. Over the previous 18 months she had lost 29 kg, yielding a BMI decrease from 35 kg/m2 to 22.9 kg/m2. She had been eating at night since her late
Studies on the genetics of eating disorders have been increasing in recent years, but only a few studies on the genetics and heritability of NES have been published. A family study conducted by Lundgren et al. found that the risk of NES was five times greater in relatives of individuals with NES than in the relatives of unaffected individuals (Lundgren et al., 2006). Similar findings were reported by Lamerz et al. who showed that the risk for NES among children of mothers with NES was 7.8 times greater than the risk among children of mothers without NES (Lamerz et al., 2005). Also a twin study reported moderate heritability for both males and females (Root et al., 2010). Our family case report provides suggestive evidence that a hereditary transmission may play a role in the development of NES. Although the prevalence of NES in both parents and children was low in the Québec Adipose and Lifestyle Investigation in Youth (QUALITY) study, results showed that night eating behavior and several features of NES (e.g., cravings to eat, sleep and mood disturbance) were quite common. It was also shown that night eating symptoms of the mothers were tied to the night eating symptoms of both sons and daughters (Lundgren et al., 2012). Our family case report supports the role of heritability of NES in line with the QUALITY study. In our sample, the most prominent symptoms of NES were nocturnal eating and morning anorexia, which was present among all of the NES cases. Like other eating disorders, NES is frequently comorbid with other psychiatric disorders (Lundgren, Rempfer, Brown, Goetz, & Hamera, 2010; Lundgren et al., 2012). We found high co-existence with mood disorders, with four of the seven cases reporting depression, dysthymia, or bipolar disorder. The association of bipolar disorder with other eating disorders such as bulimia nervosa, binge eating, as well as NES has not been clearly established (Root et al., 2010). Previous treatment trials for NES have shown improvements in NES symptoms independently of improvement in mood symptoms (Allison et al., 2013; O'Reardon et al., 2006). In this family case description, cases similarly reported
86
G.M. Sevinçer, K.C. Allison / Eating Behaviors 22 (2016) 83–86
Table 1 Detailed symptom profile of the NES cases. NES proposed crıterıa
Case 1
Case 2
Case 3
Brother of case 1
Sister of case 1
Niece of Case 1
Niece of Case 1
Evening hyperphagia Nocturnal ingestion with full awareness Morning anorexia Initial insomnia Evening depression Duration Comorbidity (life time or present) BMI (kg/m2)
+ +
+a +
−b +
+ +
− +
− +
− +
+ − + 20 years Major depression
+ − + 12 years Bipolar disorder, enuresis nocturne, somnambulism 30
−c + − 12 years Dysthymia, history of childhood abuse 22.9
+ − + 20 years Bipolar disorder
+ − + 10 years −
+ − + 7 years −
+ − + 2 years −
45.7
33.2
27.8
28.3
31.3
+ Indicates symptom is present. − Indicates symptom is not present. a Patient was unsure how much of his daily food intake he consumed after suppertime, but he reported that he starts to eat significant amounts of food continuously after midday. He also had strong urges to eat between dinner and sleep onset. b Under treatment with citalopram. c Remitted after citalopram treatment.
that some treatments were helpful for mood but were clearly not effective in reducing their nocturnal ingestions. The cases also descended from a couple who were affected by psychiatric comorbidities, namely delusional disorder and bipolar disorder. While NES was not identified in either of these persons, this linkage of psychiatric comorbidity and night eating suggests the need for further study, which would contribute to a better understanding of the etiology and treatment of NES. This family case report was limited in several ways. First some of the diagnoses were made by the family history method, rather than the family interviews. Second familial transmission was also observed for other psychiatric disorders. Finally, four of the descendants from the couple of origin for the existing NES cases were unable to be interviewed, so the current assessment represents a conservative description of the occurrence of NES in this family. 4. Conclusion This case report suggests that NES is a disorder that should be considered in psychiatry practice and that the heritability and its association with other psychiatric disorders should be assessed. Genotype studies of factors related to chronobiology, including sleep, eating and mood disorders will likely contribute to a better understanding of the etiology of NES. In the coming age of personalized medicine, identifying possible underlying genetics and other biological factors could help steer the field toward specific treatment options, particularly when a variety of psychiatric symptoms may be present. Role of funding sources There is no funding for this study.
Contributors Authors wrote this case report's manuscript together and both authors contributed to and have approved the final manuscript.
Conflict of interest Authors declare that they have no conflicts of interest.
References Allison, K. C., Lundgren, J. D., & O'Reardon, J. P. (2010). Proposed diagnostic criteria for night eating syndrome. The International Journal of Eating Disorders, 43, 241–247. http://dx.doi.org/10.1002/eat.20693 (PubMed PMID:19378289; PubMed Central PMCID: PMC4531092). Allison, K. C., Lundgren, J. D., O'Reardon, J. P., Martino, N. S., Sarwer, D. B., Wadden, T. A., et al. (2008). The Night Eating Questionnaire (NEQ): Psychometric properties of a measure of severity of the Night Eating Syndrome. Eating Behaviors, 9, 62–72 (PubMed PMID: 18167324). Allison, K. C., Studt, S. K., Berkowitz, R. I., Hesson, L. A., Dubroff, J., Newberg, A., & Stunkard, A. J. (2013). An open-label trial of escitalopram for night eating syndrome. Eating Behaviors, 14, 199–203. http://dx.doi.org/10.1016/j.eatbeh.2013.02.001 (Epub 2013 Mar 5. PubMed PMID: 23557820). American Psychiatric Association (2013). Diagnostic and Statistical Manual of Mental Disorders: fifth edition, DSM 5. Washington DC, London: American Psychiatric Publishing. Beck, A. T., Ward, C. H., Mendelson, M., Mock, J., & Erbaugh, J. (1961). An inventory for measuring depression. Archives of General Psychiatry, 4, 561–571. Lamerz, A., Kuepper-Nybelen, J., Bruning, N., Wehle, C., Trost-Brinkhues, G., Brenner, H., et al. (2005). Prevalence of obesity, binge eating, and night eating in a crosssectional field survey of 6-year-old children and their parents in a German urban population. Journal of Child Psychology and Psychiatry, 46, 385–393 (PubMed PMID: 15819647). Lundgren, J. D., Allison, K. C., & Stunkard, A. J. (2006). Familial aggregation in the night eating syndrome. International Journal of Eating Disorders, 39, 516–518 (PubMed PMID: 16609983). Lundgren, J. D., Drapeau, V., Allison, K. C., Gallant, A. R., Tremblay, A., Lambert, M. A., et al. (2012). Prevalence and familial patterns of night eating in the Québec adipose and lifestyle investigation in youth (QUALITY) study. Obesity (Silver Spring), 20, 1598–1603. http://dx.doi.org/10.1038/oby.2012.80 (Epub 2012 Apr 3. PubMed PMID: 22469955). Lundgren, J. D., Rempfer, M. V., Brown, C. E., Goetz, J., & Hamera, E. (2010). The prevalence of night eating syndrome and binge eating disorder among overweight and obese individuals with serious mental illness. Psychiatry Research, 175, 233–236. http://dx.doi. org/10.1016/j.psychres.2008.10.027 (PubMed PMID: 20031234; PubMed Central PMCID: PMC3666565). O'Reardon, J. P., Allison, K. C., Martino, N. S., Lundgren, J. D., Heo, M., & Stunkard, A. J. (2006). A randomized placebo-controlled trial of sertraline in the treatment of the night eating syndrome. The American Journal of Psychiatry, 163, 893–898 (PubMed PMID: 16648332). O'Reardon, J. P., Ringel, B. L., Dinges, D. F., Allison, K. C., Rogers, N. L., Martino, N. S., & Stunkard, A. J. (2004). Circadian eating and sleeping patterns in the night eating syndrome. Obesity Research, 12, 1789–1796 (PubMed PMID: 15601974). Root, T. L., Thornton, L. M., Lindroos, A. K., Stunkard, A. J., Lichtenstein, P., Pedersen, N. L., ... Bulik, C. M. (2010). Shared and unique genetic and environmental influences on binge eating and night eating: a Swedish twin study. Eating Behaviors, 11, 92–98. http://dx.doi.org/10.1016/j.eatbeh.2009.10.004 (Epub 2009 Oct 31. PubMed PMID: 20188292; PubMed Central PMCID: PMC2830904).
Contents lists available at ScienceDirect
Eating Behaviors
Night Eating Syndrome: Report of a family case Güzin M. Sevinçer a,⁎, Kelly C. Allison b a
Istanbul Gelisim University, Department of Psychology, Istanbul, Turkey Perelman School of Medicine at the University of Pennsylvania Center for Weight and Eating Disorders (Suite 3027) and Stunkard Weight Management Program (Mezzanine), 3535 Market Street, Philadelphia, PA 19104-3309, United States
b
a r t i c l e
i n f o
Article history: Received 6 April 2015 Received in revised form 22 March 2016 Accepted 30 March 2016 Available online 06 April 2016 Keywords: Night Eating Syndrome Familial Genetic
a b s t r a c t Night eating syndrome (NES) represents a circadian delay in the pattern of eating. As there are genetic links for other eating- and circadian-based disorders, it is likely that there is a genetic basis for NES as well. We present a family case study of three identified patients and their extensive family history of NES and co-morbid mood disorders. This case report suggested that NES may have a heritable feature, particularly nocturnal ingestions. Of the seven identified cases, four had co-morbid mood disorders, and all descended from a couple with bipolar disorder and delusional disorder. More work is needed to understand the extent of genetic influence on NES, and the relationship between NES and other psychiatric disorders. © 2016 Elsevier Ltd. All rights reserved.
1. Introduction and objective Night Eating Syndrome (NES) is characterized by recurrent episodes of night eating, as manifested by eating after awakening from sleep or by excessive food consumption after the evening meal. Specifically, at least two episodes of nocturnal eating (rising from bed during the sleep period and eating) should occur per week, or 25% or more of one's daily food intake should occur after dinner. Awareness and recall of the eating is required to be diagnosed with NES, as is significant distress or impairment caused by the disorder. An exclusion criterion for diagnosis of NES is another medical disorder or psychiatric disorder that might better explain the disordered eating pattern. An additional criterion requires that the disordered pattern of eating should be maintained for at least 3 months (Allison, Lundgren, & O'Reardon, 2010; American Psychiatric Association, 2013). Although (NES) did not ultimately make the cut as an official diagnosis, the Diagnostic and Statistical Manual, 5th Edition recognized the clinical significance of NES as a category of “Other Specified Feeding or Eating Disorder” (American Psychiatric Association, 2013). Regarding the etiology, ingestion of food seen in patients with NES is conceptualized as a delay in the circadian pattern of food intake (O'Reardon et al., 2004). Although the etiology of NES is unclear, it is
⁎ Corresponding author at: İstanbul Gelişim Üniversitesi Psikoloji Bölümü Cihangir mah. Şehit Jandarma Komando Er Hakan Öner Sk. No:1 34315 Avcılar, İSTANBUL, TURKEY. E-mail addresses: [email protected] (G.M. Sevinçer), [email protected] (K.C. Allison).
http://dx.doi.org/10.1016/j.eatbeh.2016.03.022 1471-0153/© 2016 Elsevier Ltd. All rights reserved.
thought that genetic factors may be involved (Lundgren, Allison, & Stunkard, 2006; Root et al., 2010). However, only a small number of studies have been conducted about this. Reports of familial aggregation of NES have represented a first step in understanding potential genetic and environmental influences (Lamerz et al., 2005; Lundgren et al., 2006; Root et al., 2010). In this family case report we present the familial aggregation of NES in a single family, which may provide evidence for genetic inheritance factors involved in the etiology of NES. We describe these cases in the following text.
2. Case report Three individuals from the same family were referred to a psychiatry clinic and were diagnosed as having NES by psychiatrists specializing in eating disorders. They used a routine clinical examination based on the proposed diagnostic criteria for NES (Allison et al., 2010). A remarkable finding in those cases was the discovery that several first-degree relatives also engaged in nighttime eating and were invited for an interview. Those who could not participate in a routine clinical interview were contacted for a telephone interview. The family pedigree shown below was generated following psychiatric diagnoses of the three presenting family members and from information obtained from interviewed individuals regarding the other family members. Four of the 17 family members refused to participate. Information about the psychiatric diagnosis of family members who were not interviewed was confirmed by at least two other family members to be included in this report. We have
84
G.M. Sevinçer, K.C. Allison / Eating Behaviors 22 (2016) 83–86
Fig. 1. Cases are listed in this figure who were interviewed in person as yellow, were interviewed by phone as blue, refused to participate as green, recorded with a confirmation of at least two family members as purple, and were deceased as strikethrough. (For interpretation of the references to color in this figure legend, the reader is referred to the web version of this article.)
included diagnoses when family members had been under psychiatric treatment with a recorded diagnosis. Unverifiable information obtained from family members was not included. Definite diagnosis by a psychiatrist is recorded with the confirmation of participant family members or confirmation of medical records if they were deceased. Cases are listed in Fig. 1 below who were interviewed in person as yellow, were interviewed by phone as blue, refused to participate as green, recorded with a confirmation of at least two family members
as purple, and were deceased as strikethrough. All cases that were diagnosed with NES shared a similar symptom profile. They all reported having nocturnal ingestions most days of the week for many years (2– 20 years). They also had morning anorexia and consumed N 25% of intake after dinner accompanied by marked depressive symptoms. Surprisingly most of the cases did not complain about their night eating as they considered it a normal condition. All cases were obese or overweight. Only detailed information of presenting family members are depicted below.
G.M. Sevinçer, K.C. Allison / Eating Behaviors 22 (2016) 83–86
2.1. Case 1 (Index Case) 47-year-old married housewife with a 20-year history of night eating. She felt difficulty in initiating sleep without eating something most days. She reported one or two awakenings associated with consumption of food, especially sweets and snacks 3–5 times per week. For most of the day, especially days after she had nocturnal ingestions, she reported lack of appetite until 2 pm. She had gained about 5 kg in the last 6 months, during which time her BMI rose from 29.9 kg/m2 to 31.3 kg/m2 (160 cm, 80 kg), which she attributed to increased evening calorically dense meals. Her mood was significantly depressed with existing stressful life events such as unemployment of her husband. She was under antidepressant treatment (escitalopram) for her depression and anxiety for about 3 years. She also complained of persistent lack of sexual desire. She believed that her nocturnal eating habits were normal as almost every family member experienced such an eating pattern. She reported that her son, daughter, brothers, sister, nephews and nieces all had this night eating pattern. She also reported that one of her sisters suffered from night eating for years but that sister's symptoms spontaneously disappeared 2 years ago. She denied that her nighttime ingestions negatively impacted her life. However, she complained about her weight gain. Her psychiatric examination revealed depressed mood, fatigue, anxiety, irritability, and obsessive personality features. She denied alcohol use. She increased smoking cigarettes with accompanying life stressors. She scored a 29 on the Night Eating Questionnaire (Allison et al., 2008), suggestive of the presence of night eating symptoms, and a 19 on Beck Depression Inventory (Beck, Ward, Mendelson, Mock, & Erbaugh, 1961), suggesting mild to moderate symptoms of depressed mood.
85
adolescence. She reported consuming N25% of daily caloric intake after dinner and morning anorexia. She believed that her citalopram treatment was aggravating her nocturnal eating frequency but alleviating evening hyperphagia. Despite endorsing the diagnostic criteria for NES, she only scored a 19 on the Night Eating Questionnaire (this is below the cut score of 25 suggestive of NES), and a 16 on the Beck Depression Inventory, indicating mild depressive symptoms. 2.4. Additional family cases Four additional family members were interviewed by phone and met criteria for NES (see Fig. 1). The common feature among the affected family members was the presence of nocturnal ingestions. Evening hyperphagia was not a common complaint among the cases. These other cases were as follows. The 52 year old brother of Case #1 met criteria for NES and he also reported a diagnosis of bipolar disorder for which he was treated with lithium. He weighed 140 kg and his height was reported at 175 cm for a BMI of 45.7 kg/m2. The 50 year old sister of Case #1 also met criteria for NES. She reported having nocturnal ingestions almost nightly for the past 10 years. She also described pronounced morning anorexia. She reported a height of 158 cm and a weight of 83 kg, yielding a BMI of 33.2 kg/m2. The remaining two cases were nieces of Case #1. The first was 27 years old with a height of 164 cm and a weight of 76 kg with a BMI of 28.3 kg/m2, and the second was and 30 years old with a height of 161 cm and weight of 72 kg, yielding a BMI of 27.8 kg/m2. Both nieces reported the regular presence of nocturnal ingestions with full awareness and morning anorexia, similar to the other cases presented within this family. The symptom profiles of NES cases are presented in Table 1. 3. Discussion
2.2. Case 2 The son of case #1 was a 22-year-old single male and a university student. He had been diagnosed 2 years ago as having bipolar I disorder, with a treatment of valproic acid 1000 mg/day in his military service. He had also been treated with imipramine for his nocturnal enuresis and somnambulism when he was 14. He had been euthymic for the past 3 months. He reported that his mood stability was deteriorating due to problems in his intimate relations. His height measured 175 cm and his weight was 90 kg, yielding a BMI of 30 kg/m2. He scored 25 on the Night Eating Questionnaire, just reaching the threshold suggestive of NES symptoms, and a 3 on the Beck Depression Inventory, indicating minimal depressive symptoms. He reported the same eating pattern as his mother. He stated that he could not initiate sleep unless he ate something. He reported full awareness of his awakenings to eat, with these events occurring 3–4 times per week. He did not have any sleep related complaints during the daytime. He also reported morning anorexia. However, he was unsure if he was consuming N 25% of daily caloric intake after dinner. His mood was stable, but he felt better during the daytime. 2.3. Case 3 The niece of case #1 was a 32-year-old married housewife with a 12year history of night eating. She thought that she had felt depressed for many years. She complained of somatic symptoms such as headache, fatigue, and loss of libido. She reported that she was eating just before attempting to sleep almost daily to overcome her difficulty with initial insomnia. She described a childhood sexual abuse history and was treated with antidepressants such as imipramine, venlafaxine, citalopram and escitalopram. Case 3 reported a current effort to lose weight with a strict diet. Over the previous 18 months she had lost 29 kg, yielding a BMI decrease from 35 kg/m2 to 22.9 kg/m2. She had been eating at night since her late
Studies on the genetics of eating disorders have been increasing in recent years, but only a few studies on the genetics and heritability of NES have been published. A family study conducted by Lundgren et al. found that the risk of NES was five times greater in relatives of individuals with NES than in the relatives of unaffected individuals (Lundgren et al., 2006). Similar findings were reported by Lamerz et al. who showed that the risk for NES among children of mothers with NES was 7.8 times greater than the risk among children of mothers without NES (Lamerz et al., 2005). Also a twin study reported moderate heritability for both males and females (Root et al., 2010). Our family case report provides suggestive evidence that a hereditary transmission may play a role in the development of NES. Although the prevalence of NES in both parents and children was low in the Québec Adipose and Lifestyle Investigation in Youth (QUALITY) study, results showed that night eating behavior and several features of NES (e.g., cravings to eat, sleep and mood disturbance) were quite common. It was also shown that night eating symptoms of the mothers were tied to the night eating symptoms of both sons and daughters (Lundgren et al., 2012). Our family case report supports the role of heritability of NES in line with the QUALITY study. In our sample, the most prominent symptoms of NES were nocturnal eating and morning anorexia, which was present among all of the NES cases. Like other eating disorders, NES is frequently comorbid with other psychiatric disorders (Lundgren, Rempfer, Brown, Goetz, & Hamera, 2010; Lundgren et al., 2012). We found high co-existence with mood disorders, with four of the seven cases reporting depression, dysthymia, or bipolar disorder. The association of bipolar disorder with other eating disorders such as bulimia nervosa, binge eating, as well as NES has not been clearly established (Root et al., 2010). Previous treatment trials for NES have shown improvements in NES symptoms independently of improvement in mood symptoms (Allison et al., 2013; O'Reardon et al., 2006). In this family case description, cases similarly reported
86
G.M. Sevinçer, K.C. Allison / Eating Behaviors 22 (2016) 83–86
Table 1 Detailed symptom profile of the NES cases. NES proposed crıterıa
Case 1
Case 2
Case 3
Brother of case 1
Sister of case 1
Niece of Case 1
Niece of Case 1
Evening hyperphagia Nocturnal ingestion with full awareness Morning anorexia Initial insomnia Evening depression Duration Comorbidity (life time or present) BMI (kg/m2)
+ +
+a +
−b +
+ +
− +
− +
− +
+ − + 20 years Major depression
+ − + 12 years Bipolar disorder, enuresis nocturne, somnambulism 30
−c + − 12 years Dysthymia, history of childhood abuse 22.9
+ − + 20 years Bipolar disorder
+ − + 10 years −
+ − + 7 years −
+ − + 2 years −
45.7
33.2
27.8
28.3
31.3
+ Indicates symptom is present. − Indicates symptom is not present. a Patient was unsure how much of his daily food intake he consumed after suppertime, but he reported that he starts to eat significant amounts of food continuously after midday. He also had strong urges to eat between dinner and sleep onset. b Under treatment with citalopram. c Remitted after citalopram treatment.
that some treatments were helpful for mood but were clearly not effective in reducing their nocturnal ingestions. The cases also descended from a couple who were affected by psychiatric comorbidities, namely delusional disorder and bipolar disorder. While NES was not identified in either of these persons, this linkage of psychiatric comorbidity and night eating suggests the need for further study, which would contribute to a better understanding of the etiology and treatment of NES. This family case report was limited in several ways. First some of the diagnoses were made by the family history method, rather than the family interviews. Second familial transmission was also observed for other psychiatric disorders. Finally, four of the descendants from the couple of origin for the existing NES cases were unable to be interviewed, so the current assessment represents a conservative description of the occurrence of NES in this family. 4. Conclusion This case report suggests that NES is a disorder that should be considered in psychiatry practice and that the heritability and its association with other psychiatric disorders should be assessed. Genotype studies of factors related to chronobiology, including sleep, eating and mood disorders will likely contribute to a better understanding of the etiology of NES. In the coming age of personalized medicine, identifying possible underlying genetics and other biological factors could help steer the field toward specific treatment options, particularly when a variety of psychiatric symptoms may be present. Role of funding sources There is no funding for this study.
Contributors Authors wrote this case report's manuscript together and both authors contributed to and have approved the final manuscript.
Conflict of interest Authors declare that they have no conflicts of interest.
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